Archive for January, 2013

Should I be taking aspirin?

Wednesday, January 30th, 2013

I take a dose equivalent to 1/4 tablet of aspirin

One of our friends recently told my wife she'd stopped taking aspirin after a news report linked regular use of the medication to macular degeneration. We've both taken 81 mg of aspirin a day and, after I'd heard that people may not absorb the enteric coated form well (and I couldn't find any other form in that size at the local drugstore), I'd ordered ten bottles of chewable orange-flavored aspirin online from Amazon.

Then I decided to read the medical reports that our friend's recommendation had been based on. She doesn't have a medical background and hadn't looked at the original data, but instead had seen a warning in a newspaper article. Let's start at The New York Times blog. On Dec 12, 2012 they published an article by Anahad O'Conner titled "Aspirin Tied To Rare Eye Disorder."

It's a very well-worded article written by a 31-year-old, Yale-educated Times reporter who writes a weekly science column and has published two books He notes the article he based his piece on was from JAMA with the lead author, Dr. Barbara Klein, being a professor of ophthalmology at the University of Wisconsin, Madison. Since I'm a UW graduate (BS 1963, MD 1966), I was particularly interested in her study.

It used data from the Beaver Dam Eye Study, started in 1988-1990 and concluded in 2010. O'Connor very appropriately noted this was an observational study, not a prospective, controlled research project. In other words a group of ~5,000, aged 43 to 84, agreed to have regular eye exams and reports were published after the 5-, 10-, 15- and 20-year followups.More than 300 publications have resulted from this project with data supporting a relationship of cataracts and age-related macular degeneration (AMD) to cigarette smoking.

Klein's paper stated that an estimated 19.3% of US adults take aspirin on a regular basis. It's commonly recommended for anyone who has had a heart attack (secondary prevention), but many   of us who've never had evidence of coronary vascular disease also take aspirin. This is primary prevention and is controversial with some data suggesting reduction of heart attacks in men over 45, but not women, although they may have a 17% reduction in stroke incidence.

A senior who has AMD may need a magnifying glass.

A January 21,2013 article from an Australian group reported a two-fold increase in AMD of a particular type, independent of smoking habits. Nearly a quarter of regular long-term aspirin users developed neovascular AMD, two and a half times the percentage of those who did not regularly take aspirin.

A 2001 paper in the Archives of Ophthalmology reported a randomized, double-masked, placebo-controlled study of low dose aspirin (one adult tablet every other day) plus 50 milligrams of beta carotene (a vitamin A precursor rated possibly effective in treating advanced AMD) among over 20,000 US male physicians aged 30 to 84 in 1982. The study was stopped after ~5 years due to a statistically extreme reduction (44%) in first heart attacks. There were fewer cases of AMD in those taking low-dose aspirin than in those who got the placebo.

There's also some data supporting aspirin's role in cancer prevention, especially in malignancies of the colon. Here the benefit was unrelated to aspirin dose (75 mg/day and up), but increased with age.

So let me look at my own risks: my dad had a large polyp in the earliest part of the colon, an area hard to see even on colonoscopy. It was initially felt to be benign, but later had some areas of low-grade malignancy. He also had macular degeneration in his remaining eye  diagnosed at age 90+ (the other eye having been removed nearly sixty years previously after a bad cut and a subsequent infection). My brother died of a heart attack at age 57 and my mother had a heart attack at age 74 with a cardiac arrest; (Dad resuscitated her and she lived to age 90).

The editorial that accompanied the recent JAMA article is thoughtful and impressive. Its title was "Relationship of Aspirin Use With Age-Related Macular Degeneration: Association or Causation?" and it concludes "From a purely science-of-medicine perspective, the strength of evidence is not sufficiently robust to be clinically directive." It then switches to a different viewpoint, the art-of-medicine perspective, saying maintaining the status quo is currently the most prudent approach, especially in secondary prevention (someone who has already had a cardiovascular event). For those of us who haven't, the risks versus benefits should be individualized based on our own medical history and value judgement.

I'm going to discuss this with my own physician but not stop taking a chewable 81 mg aspirin daily until I do.

Progress on the painkiller front

Sunday, January 27th, 2013

In the January 25, 2013 online edition of The New York Times I found a highly significant article titled "F.D.A. Likely to Add Limits on Painkillers." An advisory panel to the Food and Drug administration wants to strengthen the current rules about such drugs as Vicodin, a frequently prescribed powerful pain pill.

Money sometimes blocks the adoption of sensible rules

Similar recommendations failed to make it through Congress last year; they were lobbied against by business interests with considerable heft behind them.

Now Vicodin and other drugs made from hydrocodone aren't the worst problem, but, as you'll see, they are a way to call attention to medications that for the past four years have caused more deaths in the United States than traffic accidents, or those from illegal drugs including heroin and cocaine.

I went back to an article in the Journal of the American Medical Association, AKA JAMA. It was published on Dec 14, 2011 in the section called "Vital Signs," and was a CDC look at overdoses of prescription opioid pain relievers (OPRs) in the US, especially during the 1999-2008 time frame. The news was stark; in 2007 nearly 100 people died from these drugs every day, with death rates that have tripled since 1991.

Between 1999 and 2010 the sales of OPRs quadrupled with enough prescribed to give every single one of us US adults a standard dose of these medications every 4 hours for a month. The health-care cost of abuse of these drugs is staggering, estimated at $72.5 billion a year.

Of the total number of US 2008 deaths from drug overdoses (36,450), OPRs were involved in 14,800 and the years of potential life lost before age 65 was comparable to the figure from motor vehicle accidents. I was startled, but in retrospect not entirely surprised that a study showed 3% of American physicians accounting for 62% of the OPRs prescribed.

Some of those doctors are anesthesiologists, oncologists or other physicians fully trained in pain control and working in highly specialized hospital-associated units. Their use of these medications is appropriately aimed at patients with cancer, those with severe acute injuries and perhaps some others whom almost all of us would agree should have whatever it takes to minimize agonizing pain.

But some who prescribe for dough can end up in jail

Others in the group of "mega-prescribers," however, may not be pain specialists; they could be working for "pill mills." That has happened in a number of states with some of those doctors being accused at this stage and several others being convicted and facing jail sentences.

But the new rules, which have to be approved by the FDA and then by the Department of Health and Human Services before they actually take effect, make enormous sense to me: refills forbidden without a new prescription; no fax or phone prescriptions, only written ones; and drug distributors being forced to store OPRs in special vaults.

The Times article today notes the panel was not monolithic in their voting (19 to 10) with some highly skeptical that the suggested changes would do much to alter the current surge of inappropriate or illicit drug use in America. One commented that oxycodone-containing products already are in a more restrictive category.

One of the subject matter experts quoted was Dr. Nathaniel Katz, an anesthesia assistant professor at Tufts University medical school. Katz served as Chair of the FDA's Advisory Committee, Anesthesia, Critical Care, and Addiction Products Division, from 2000 to 2004 and thinks the recommended rule was largely symbolic, giving a message both to doctors and patients. He commented that the OPRs the panel was voting on are a relatively minor player. Katz now devotes much of his time to a clinical research company that's attemting to develop new treatments for pain.

Vicodin and like drugs containing hydrocodone are the most widely prescribed OPRs, but are responsible for a minority of deaths with medications containing oxycodone or methadone, although less commonly given to patients, accounting for two-thirds of the drug overdose deaths.

So the question now is whether the proposed new rules make it over the remaining hurdles.

I hope they do.


There may be hope for those who've lost their sense of smell and taste

Tuesday, January 22nd, 2013

Ah, that's vanilla

I was reading JAMA, the Journal of the American Medical Association, in this case the January 9, 2013 edition, and came upon an abstract of an article from an ENT (Ear, Nose and Throat, AKA Otolaryngology) journal I wouldn't look at normally. The pilot study authored by an MD, PhD and two colleagues  from the Washington, DC, Taste and Smell Clinic, involved ten patients who had lost their sense of smell and taste (they're clearly related as both my wife and I can attest). The causes of their condition, medically termed hyposmia and hypogeusia, were varied.

Let's start with a definition: a pilot study is a small-scale preliminary research project prior to attempting a larger, more expensive and expansive effort. So this study is not the last word on the treatment of the two conditions, but only a beacon of hope for those of us who no longer can taste and smell with the same acuity we once did.

These are common conditions, especially as we age. I'll give you links to the NIH's MedlinePlus website patient information for impaired smell and for impaired taste, but my own issue with smell and taste started with allergies and nasal polyps in the 1970s and my wife lost her sense of smell, for unknown reasons, when she was in her late 60s. One of the underlying concepts is much of what we perceive as taste is actually smell; the tongue can only detect four or perhaps five tastes: salty, sour, bitter and sweet are the conventional four I was taught in medical school (probably in grade school in a rudimentary fashion); the fifth is umami, a taste known to the Japanese since the early 1900s and often thought of as meaty or savory (it's best associated with the amino acid glutamate, sold as MSG and some people have reactions to it).

Dr Steven Bromley, now a neurologist in New Jersey, wrote a superb paper on smell and taste disorders when he was still a resident. In the first place those issues are common in the general population, but should not be taken as routine. The most common causes are nasal and sinus disease, URIs and head trauma (10% of the latter group have olfactory impairment). A host of medications and a number of more significant diseases can be causative factors, so especially for those who suddenly lose these senses, a medical review may be in order.

Compensating for loss of smell and taste by adding excessive amounts of sugar and/or salt to your diet can lead to serious consequences. We tend to use a host of spices without salt and to tell guests that we under-salt menu items, so they an add whatever they're used to at the table. When we cook for ourselves we add no salt; for company we tend to use 1/2 to 1/3 of whatever the recipe recommends.

Someday we may be able to use a nasal spay to help our sense of smell.

Back to the pilot study: they used both oral and nasal theophylline, a medication historically used for patients with asthma and other lung diseases. The oral form was given for two to twelve months, then stopped for a few weeks (3 to 12) and replaced by a nasal spray of the drug. Past experience with the oral medication showed potential for side effects they wished to avoid. The nasal spray worked better in more patients (8 of 10 versus six of ten) with no adverse effects being noted.

This is obviously only a preliminary study; don't ask your physician for a nasal spray of theophylline yet. Much larger and longer clinical studies need to be done and any of us without an obvious reason for loss of smell and taste should be evaluated for the underlying cause.

But it makes me optimistic that someday some of us may be able to regain those lost senses. Besides enhancing our meals, the other uses of smell and taste, the protective ones that help us distinguish danger (smoke, toxins, pollutants, spoiled food), may be improved.

Here's hoping.

Prolonged coughing: part III: Is it just a viral URI?

Friday, January 18th, 2013

Having had two of the infectious causes of a cough, bronchitis and a viral upper respiratory infection (URI), I was intrigued to hear that friends suffered the same sort of episodes I had gone through. Having written about whooping cough and its resurgence and then about influenza, another potential cause, I decided to explore both chronic coughing and the common cold.

He should be home, not spreading germs among his co-workers

Medicine's home page on URIs has lots of links to supplementary information. The average adult has two or three colds a year and kids have more than that, so we all need to be prepared for upper respiratory infections, while deciding which illnesses require a visit to our doctor.

The CDC has a page on treating the symptoms of a viral URI. The first thing to notice is you're told that viral infections cannot be treated with antibiotics. When I was seen ten days ago for a cough much like the one I had with my October illness I had no fever, no symptoms suggesting a sinus infection, was coughing up clear fluid (not thick green stuff), wasn't wheezing and was told I had no signs of a bacterial throat infection requiring a throat culture.

What I did have was a severely sore throat and an incredible cough in double paroxysms that worsened when I tried to lie down. I had spent the preceding night sitting up on our couch which has foot rests at both ends. So I got three medications: a prescription cough suppressant that I took in half-dose at bedtime (HS) only, and two over-the-counter meds, one for the sore throat (ibuprofen) and one to loosen secretions (guaifenesin with Mucinex being the brand name). I was also advised to hydrate orally and via breathing, drinking three quarts of water a day and using a humidifier.

I slept well after that, but used two pillows instead of one. Yesterday I didn't take the HS med and today I quit the Mucinex; the sore throat had only lasted three days, so I've been off ibuprofen for a week.

The Mayo Clinic website says over 100 different viruses can cause the common cold with rhinovirus being the most frequent culprit. Other sites say 200 viruses can cause similar symptoms. But I keep hearing about people having prolonged coughs this year. Is something unusual going on?

What's the cause of her cough?

WebMD defines an acute cough as one that lasts less than three weeks and a chronic cough as one that extends for more than eight weeks. Well...our West Coast friend we visited in October had a cold with a subsequent six-week  of hawking and I had bronchitis with nearly four weeks worth of barking as a result. So both episodes fell in the middle of that range; why did our coughing episodes last so long?

I found a 2009 CNN webpage on chronic coughs and their causes. Again they use the eight-week definition for chronic and neither my friend in Washington state nor I have met that cutoff. I'm aware that whooping cough and influenza are certainly contributing to the upswing in the tales I've heard of those who whoop, hawk, rasp and cough for longer than usual. But I didn't write about asthma/allergies, chronic obstructive pulmonary disease (COPD includes emphysema and chronic bronchitis), gastroesophageal reflux disease (AKA GERD), air pollution. or the class of medications called ACE inhibitors (used for high blood pressure and other illnesses).

The CNN article said up to 40% of nonsmokers in the US and Europe have noted a chronic cough at one time or another in their life; it's among the most frequent reasons for a seeing your doctor.

Have you been one of my cohorts with an unusual cough this year? If so, is it acute or chronic? Have you seen your physician or do you need to do so?


Coughs, colds and flu Part 2: what's new with flu?

Thursday, January 17th, 2013

Like we always do, we got our flu shots early, this year on the day after they first became available. Several friends said they were going to wait a few months; I'm always concerned that the supply of vaccine will be gone by then and as former Air Force medical staff, we got in the habit of being told, "It's time for your flu shot." Our timing was excellent; flu struck earlier than usual (it typically peaks in February). And the New York State Department of Health agreed that the best time to get a flu shot is as soon as the vaccine is available.

This is a bad flu season with not only an early peak in case numbers, but also an unusual virus. I looked at the flu primer, updated for the 2012-2013 season, by arstechnica, a technology news and information website. The influenza virus has an outer layer of proteins around its genetic material core; the specific proteins of the coating determine what kind of cells the flu bug can attach to and therefore infect  (they also act as chemicals that our immune system can react to), while the inside core lets the virus take over the cell and make new viral particles.

flu virus with Hs and Ns sticking out; I think of them as arms and legs

The most important proteins in the outside coating are called hemagglutinin (H) and neuraminidase (N); there are a variety of each with the CDC saying there are 16 different Hs and 9 Ns. Three variants, H1N1, H1N3 and H3N2, are currently infecting humans while the highly pathogenic H5N1 avian flu was of major concern in recent years. As of January 5th, 2013, the influenza A H3N2 virus was the predominant strain causing flu in the United States.

There are three types of influenza viruses, logically enough labeled types A, B and C. Type A can affect both humans and some animals and is responsible for the largest and most widespread  outbreaks termed pandemics. Type B only occurs in people and usually is responsible for less severe reactions; it is not classified by subtypes and isn't responsible for pandemics. Type C, also only a human strain, doesn't cause epidemics, much less pandemics and doesn't lead to severe illness. The yearly vaccine protects against two type A strains (H1N1 and H3N2) and one type B virus with specific viruses chosen based on scientific estimations of what the coming year's flu will most likely be. The CDC webpage titled "Key Facts about Seasonal Flu Vaccine" mentions three different flu shot varieties and one nasal vaccine; the shots are all made from inactivated viruses (one is a high-dose form designed for those of us 65 and older). The nasal spray is made from live attenuated (weakened) viruses and can be given to anyone age 2 to 49 who is not pregnant and is otherwise healthy.

Now civilian hospitals in a number of areas have fired staff members who refused to get vaccinated for influenza. Some of those former hospital employees are threatening to sue, but my own viewpoint is the hospitals have done the right thing. The last thing I think they need is their own docs, nurses, techs and other staff infecting patients who are already ill with something that may make them more likely to have flu complications.

What about pregnant women who work for the hospital? Should they get flu shots or does that place their fetuses at risk? I wasn't sure until I saw the 1-16-2013 edition of the New England Journal of  Medicine. A Norwegian study performed during the 2009 flu pandemic had convincing figures: there were 117,347 eligible pregnancies and 54% of the women were vaccinated in their second or third trimester with substantial reduction in moms getting the flu.

Pregnant women in this study who did have influenza had an increased risk of fetal death. Vaccination did not increase fetal mortality (and may actually have reduced it).

epidemics are many more cases than usual; pandemics have widespread cases

The real problem with bad cases of flu is bacterial coinfection, often with "bugs" that colonize our nasopharynx area: staph aureus, strep pneumoniae and strep pyogenes. This highly significant flu complication was present in almost everyone who died in the great flu pandemic in 1918 and, even today, with our panoply of antibiotics, frequently occurs in influenza victims who require ICU care. A third of those needing such intensive care in the 2009 H1N1 pandemic had such a combined illness.

The CDC has a superb webpage, "What you should know for the 2012-2013 Influenza Season," and I strongly recommend using that as a source.

Here's hoping you get a yearly vaccination and don't ever get the flu.


So why are you coughing? Part one: pertussis

Sunday, January 13th, 2013

I had planned to write a followup post on personality psychology, but got sidetracked by a severe sore throat and a peculiar cough. I barked in a double rhythm over and over again. Three months ago I had an episode with a similar cough, was eventually diagnosed as having bronchitis and was treated with a short course of antibiotics. This felt more like a viral upper respiratory infection (URI), but I had problems swallowing (the med-speak term is dysphagia). I ate hard boiled egg whites and apple sauce and yogurt for the first two days of this illness. That was four days ago and I'm much better now; the  sore throat is gone and last night I got eight plus hours of sleep, uninterrupted by any coughing spells. I have a virus, but there's been a lot of concern at the national level about several diagnostic possibilities that I turned out not to have.

The first issue to mention is pertussis, AKA whooping cough. When I had my similar episode months ago, the friends we were visiting in Washington asked if I might have whooping cough. They said their state was in the midst of a pertussis epidemic. Now I had thought of it as a). a disease affecting the very young and b). a thing of the past because of vaccinations.

It turns out I was wrong on both counts. The National Library of Medicine's website outlines the entity: it's bacterial, not viral, in origin, is a URI, lasts ~ 6 weeks, and is most dangerous to infants. But it can affect us at any age and with most youngsters being vaccinated it's more commonly seen in adolescents and adults (2012 estimates were 100 cases per 100,00). Its hallmark is a peculiar cough that starts when the infected person tries to take a breath and ends in a "whoop." That paradigmatic sound is rare in those under six months of age and in adults.

Whooping cough doesn't just affect Botswana

And, in contrast to my thought that pertussis was something that I studied in the 1960s, but of little consequence today, the CDC has a webpage on pertussis outbreaks that classify it as an endemic disease (i.e., one that's always around) that has moderate peaks every 3-5 years and some severe outbreaks.

I found an article online from the Huffington Post from July of 2012 that said yearly whooping cough cases, prior to the development of an effective vaccine in the 1940s, used to number in the hundreds of thousands . Then case reports fell markedly to less than 5,000 per year. That lasted about twenty-five years with a distinct climb in the 1990s. In 2004, 2005 and especially in 2010, case numbers soared to greater than 25,000.

The CDC's provisional figures for 2012 were much higher, over 41,000 cases with 18 deaths, mostly in infants younger than 3 months.

I remembered that the American Medical Association had recently urged that all adults 65 and older get an update on their vaccination for pertussis. The easiest way appeared to get a Tdap shot, a booster vaccination against tetanus (lockjaw), diphtheria and pertussis. My problem was I had a tetanus vaccination in April, 2012, after cutting myself on a piece of metal, but I'm pretty sure they used Td (i.e., a vaccine for tetanus and diphtheria, but not pertussis). That apparently had been the recommendation in past years for those of us over 65. I've asked my physician to track down which I received and will ask, if I did get Td, if it's safe to get Tdap now, nine months later.

Diphtheria, formerly a major killer of children, is now extinct or nearly so in the United States, with no confirmed cases here since 2003 (That's not the case elsewhere in the world!). So why don't they give adults a booster with "Tap," a tetanus and pertussis vaccine? Perhaps it's because adults often travel overseas  and could conceivably be exposed to diphtheria.

This person may need a tetanus booster; how about Tdap?

A March 2012 American geriatric panel suggested it would be relatively simple to give older adults Tdap. It's also relatively difficult to diagnose whooping cough from other cough-causing diseases in older adults and pertussis can be dangerous in those over 65 according to a Duke University geriatrics professor.

Many of us in the 65+ age range have young grandchildren (or even great grandchildren) and should avoid infecting them with a serious disease. The Advisory Committee on Immunization Practices has advised we get Tdap when we need a tetanus booster and is looking into the possibility of giving it to those who've had a similar shot once before.




When do we stop changing?

Saturday, January 5th, 2013

One of the best ways to answer important questions

I was driving home recently listening to my car radio and PBS had a report on a new study by Harvard psychology professor Daniel T. Gilbert. He had been wondering, or so PBS said, "Am I going to keep changing as I grow older?" He initially didn't think so, but designed a study to determine if others also had the same point of view. Rather than run a ten year project, and see if self-prediction of coming changes (or lack thereof), is accurate, he came up with a clever way around the time span needed. It caught my "ear," and I wanted to know more about the subject.

I got home and read about the same study in The New York Times the next morning. Their article was called "Why you won't be the person you expect to be" and was quite interesting. But I really wanted to see the published article itself.

So I tried to find it online in the journal Science and was only able to print an abstract (or I could have purchased the whole article for one day for $20 or subscribed for $115 as an emeritus). Neither of those options enthralled me. There had to be more than one way to skin that cat. So I googled the author's name, found his webpage and, lo and behold, he had a link to his publications including the entire article which apparently came out  in Science on January 4th, 2013. I decided this was an entirely legal way to be able to peruse the study and it's a fascinating one.

Gilbert and two professorial colleagues, Jordi Quoidbach and Timothy D. Wilson, looked, in multiple ways, at the preferences, values and personalities of a large group (>19,000) of young, mid-range and somewhat older adults ranging in age from 18 to 68. The researchers wondered why people often make decisions they later come to regret and thought one major cause may be that most of us think the person we are today is the same as the person we will be in five, ten or twenty years. We know we've changed a lot as we grew up, but we don't expect to do so in the future. Gilbert et al. think this adversely affects our decision-making and call the misconception the "End of History Illusion."

The three scientists did a series of studies comparing how adults at age X (e.g., 28), would complete a standardized Ten Item Personality Inventory as if they were ten years younger than their current age or how they thought they would answer if they were ten years older. The questionnaire measured personality in its five traits: extraversion-introversion, emotional stability, openness to new experiences, agreeableness and conscientiousness.They found that older study subjects, as expected, reported and predicted less personality change, but everyone thought they were now at a relatively stable stage in their personality growth.

A previously reported study had actually followed over 3,800 adults aged 20 to 75 over a ten year period (the MIDUS study, midlife development in the United States) looking at many parameters. One of those matched the personality aspect of Gilbert's study with similar findings.

In six subsets of study participants, the current article also examined predicted and reported changes in core values (ideals and principles) and preferences (likes and dislikes). The results? Ditto...we all think we've changed more then than we will in the future.

Our kids and grandkids can help us keep learning

Overall it was a superb study, well worth pondering; it may even alter the way I think about myself!

The chairman of Northwestern's Psychology Department, Dan P. McAdams is quoted in the NYT  article as saying, "The end-of-history effect may represent a failure in personal imagination." His own research is about personal narratives, stories we construct about our past and future lives.

I plan to read some of his work and write about it in my next post.


Pain meds Part IV: Finis

Thursday, January 3rd, 2013

Some pain pills come the legal way

I'm finally going to end this four-part series of posts on pain medications, their relatives and the issues with the "normal" prescription variety. Today I'm writing about legal drugs, used to control acute pain, chronic cancer-related pain (CCRP) and often for chronic non-malignant pain (CNMP). Of course they're also used for illegal purposes...frequently.

My series began to expand when I read an article in The Wall Street Journal in mid-December titled "A Pain-Drug Champion Has Second Thoughts."  It told how Dr. Russell Portenoy, a New York academic pain specialist, Professor of Neurology at the Albert Einstein College of Medicine, trustee of the American Board of Hospice and Palliative Medicine and a past president of the American Pain Society has switched his point of view on pain pills for CNMP.

Twenty years ago he spear-headed the movement to both help those with chronic pain and to advocate the use of opioids that many physicians avoided, fearing their addictive properties. Those would include drugs such as OxyContin, Percocet  and Vicodin (which a federal advisory panel recommended be banned in 2009), each of which rose to the top ranks of widely prescribed drugs. The opioids, when combined with over-the-counter pain medicine (e.g., aspirin, ibuprofen or acetaminophen) are in a less controlled status than the parent drug alone.

As far back as 1998 one prominent pain specialist urged be put higher on the controlled substance list which has a hierarchy from Schedule I  (authorized for research only) to Schedule 5  (e.g., narcotic-containing cough meds). What's the difference?  If a drug is in Schedule II it requires a manually signed prescription with no refills, whereas Schedule III drugs can be called in to a pharmacy for refills.According to the DEA, a Schedule II drug has a 30-day prescription length and one needs a new prescription for refills; Schedule III and IV drugs have no mandatory controls on length of prescription (insurers may limit), and one can receive five refills in six months.

Neonatal ICUs often have newborns from addicted mothers

As "Pain Pill Mills" spread widely across America people began to have second thoughts. An article from the WSJ six days ago told the story of "Pain Pills' Littlest Victims," babies born to mothers addicted to drugs such as oxycodone. These infants have withdrawal symptoms, require intensive care and typically cost Medicaid over $50,000. In 2009 there were over 13,000 of such newborns, requiring $720 million of hospital care. Hospitals have been ill-prepared for their care and had no fixed protocols for what is termed "neonatal abstinence syndrome." These newborns may be delivered to moms who have taken a variety of drugs: amphetamines, barbiturates; cocaine, benzodiazepines as well as opiates. Their care needs depend on what drug, how much and how long it's been used, how the mother's body metabolizes it and whether the baby was born prematurely. States including Florida, West Virginia and Kentucky have had considerable numbers of these afflicted newborns with hospitals in an area north of Tampa reporting up to 30% of their NICU patients treated for withdrawl from opioids.

Florida passed a law stating only doctors can operate pain clinics, so some owners have moved to other states without such restrictions. Deaths from two of the most commonly used opioids have decreased in Florida since the law went into effect, but Georgia's rules aren't as strict so a former used-car dealer from Florida opened a pain clinic there in 2010, hired two physicians through Craig's List and soon was dispensing RXs to 50 patients a day. Georgia had 10 such pill mills in 2010 and 125 in late 2012.

Overall accidental deaths from heroin overdoses increased slightly during the 2000 to 2009 time frame and cocaine-related deaths fell; both are under the 5,000 per year mark. But fatalities from painkillers increased markedly during the same period, to over 15,000 per year. A WSJ article published online Dec. 5, 2012 told the story of a 23-year-old woman who was one such casualty. Drug overdoses are now the most common cause of US accidental deaths, passing traffic-related casualties in 2009.

Our country spends roughly $15B per year combating illegal drug trafficking, mostly concentrating on other countries. It's time and past time to fight the pain pill problem here at home.